A manifesto for nephrologists

Much has been made about the steady decrease in the number of U.S. medical school graduates choosing to pursue nephrology as a career.  Even among nephrologists, both those in private practice as well as academia, there has been substantial hand-wringing on this issue.

My more pessimistic colleagues see a subspecialty in decline, which they attribute to a myriad of factors.  These include the encroachment on our “turf” by other sub-specialists (intensivists performing continuous renal replacement therapy, cardiologists performing ultrafiltration, rheumatologists managing lupus nephritis, and transplant surgeons managing immunosuppressive medications).

Others attribute this declining interest in nephrology to the fact that the field is disproportionately reliant on government payors, and as such under the constant pressure of declining reimbursements in a field where income is on par with physicians that have less post-residency training (such as hospitalists).  In all candor, these naysayers raise valid points.  I would like to challenge this perspective, however.

It is increasingly clear that the future of health care delivery will involve the collaboration of physicians of various specialties and subspecialties with other allied health professionals.  Who is better suited for this herculean endeavor than a nephrologist?  After all, we round in dialysis units several times per month with a multi-disciplinary team that includes dieticians, nurses, and social workers.

In some cases, we have even learned to relinquish those aspects of a patient’s care that may be better performed by other members of our team (e.g., the access nurse, or the motivated dietician who manages the patient’s mineral and bone disease).   Lest anybody forget, it was no easy undertaking to cajole us prima donnas to play nicely in the sandbox with each other.

It is also increasingly clear that in the future of health care delivery we will be judged (and compensated) based on our ability to provide quality care that is cost-conscious.  What other field has been managing patient’s in an environment where payments have been bundled since 2008?  Many of us even serve as medical directors, overseeing budgets of entire dialysis units in a time when resources are increasingly scarce.

Additionally, we are comfortable providing quality care across different clinical settings.  We have been treating with outpatient intravenous antibiotics long before the introduction of PICC’s and visiting nurse services.  We have been scheduling extra outpatient dialysis treatments for our patients that are volume-overloaded long before this new era of cost-consciousness.

It seems to me that our chosen field of nephrology has prepared us well as the future of health care delivery in the United States continues to evolve to a more integrated and cost-conscious model.  Our unique experiences have well-positioned us to become the leaders of tomorrow as accountable care organizations are formed, and we need to continually remind internal medicine residents about this.

Only then will interest in nephrology as a career begin to rebound.

James M. Pritsiolas is a nephrologist and can be reached on Twitter @Nephro_Doc.


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